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Recent data do not exist regarding fourth-year medical students' performance of and attitudes toward procedural and interpretive skills, and how these differ from third-year students'.Cross-sectional survey conducted in February 2006 of 122 fourth-year students from seven U.S. medical schools, compared with their responses in summer 2005. Students estimated their cumulative performance of 22 skills and reported self-confidence and perceived importance using a five-point Likert-type scale.The response rate was 79% (96/122). A majority reported never having performed cardioversion, thoracentesis, cardiopulmonary resuscitation, blood culture, purified protein derivative placement, or paracentesis. One fifth of students had never performed peripheral intravenous catheter insertion, phlebotomy, or arterial blood sampling. Students reported increased cumulative performance of 17 skills, increased self-confidence in five skills, and decreased perceived importance in three skills (two-sided P.05).A majority of fourth-year medical students still have never performed important procedures, and a substantial minority have not performed basic procedures.

Purpose We assessed the feasibility of a large randomized trial intended to determine whether low-dose heparin prophylaxis given throughout hospitalization reduces mortality and morbidity in general medical patients. Subjects and methods Hospitalized general medical patients aged more than 60 years at 5 Department of Veterans Affairs (VA) medical centers were randomized to receive enoxaparin 40 mg or identical placebo, given daily by subcutaneous injection until hospital discharge. Outcomes included total mortality at 90 days (the primary outcome) and 1 year, and occurrence in the VA hospital within 90 days of symptomatic deep venous thrombosis, pulmonary embolism, and major bleeding. Results Only 7.6% of hospitalized patients aged more than 60 years were eligible for the study, although a chart review had predicted 25%. The principal exclusions were prior indication for anticoagulation, anticipated need for anticoagulation, contraindication to heparin, expected hospitalization less than 3 days, and "supportive/palliative care only" status. We randomized 140 patients into each group, 28% of target recruitment. The groups were well matched by age and comorbidities. Death occurred in 13 patients receiving enoxaparin and 14 patients receiving placebo at 90 days (relative risk 0.93, 95% confidence interval 0.26-1.59), and in 36 and 32 patients, respectively, at 1 year (relative risk 1.13, 95% confidence interval 0.66-1.60). Clinical thromboembolic events occurred in 5 patients receiving enoxaparin and 8 patients receiving placebo, and major bleeding occurred in 2 and 5 patients, respectively. Conclusions The pilot study indicated that the full study was not feasible. The decision to use prophylaxis pertains to only a small proportion of general medical patients hospitalized at VA medical centers, and this proportion is overestimated by chart review. The effect of low-dose heparin prophylaxis on clinical outcomes in hospitalized general medical patients remains uncertain.

Background: Previous studies have shown that medical students and post-graduate train-ees need to improve their proficiency in cardiac auscultation. Technologic advances have created new learner-centered opportunities to enhance proficiency in this important physical examination skill. Objectives: We sought to determine if technology-based, self-directed learning tools improved the cardiac auscultation skills of third-year medical students. Methods: Sixteen (16) third-year medical (M3) students were exposed to three educational inter-ventions: a one-hour cardiac auscultation lecture that featured computer-generated heart sounds, a PDA-based heart sounds/murmur form and a web-based cardiac auscultation program. Thirteen (13) internal medicine (IM) residents who served as a comparison group attended a cardiac auscultation lecture identical in content and format to the student lecture. At the end of the study period, we evaluated the ability of both groups to accurately identify heart sounds and cardiac murmurs via a twelve-item performance-based examination utilizing computer-generated heart sounds. Results: Following our teaching interventions, findingsM3 students correctly identified 80% of the computer-simulated heart sounds/murmurs while the comparison group of IM residents accurately detected 60% of the same cardiac findings (p

To determine the frequency of ACE inhibitor cough in an outpatient medical clinic population, a cross-sectional epidemiologic survey using mailed questionnaires was done. Patients were randomly selected from a computerized hospital pharmacy data base. The overall prevalence of cough was 19 percent in the ACE inhibitor groups compared with 9 percent in the hydrochlorothiazide-treated group. The observed odds ratio for cough among ACE inhibitor users was 2.3 (95 percent CI, 1.02 to 5.00). This study is the first systematic investigation of frequency and characteristics of ACE inhibitor cough that includes a control group. Our results suggest that cough may more frequently accompany treatment with ACE inhibitors than has been previously reported. We recommend that physicians specifically inquire about cough in patients taking an ACE inhibitor. Recognition of this side effect may prevent unnecessary testing and treatment of patients receiving ACE inhibitors. (Chest 1991; 99:36–39)

The mini-clinical evaluation exercise (mini-CEX) has been used to assess clinical skills of 3rd-year medical schools. However a PDA-based mini-CEX has not been developed or evaluated before. Our objective was to determine the feasibility, implementation, and user satisfaction with a PDA-based mini-CEX.Third-year medical students at the Medical College of Wisconsin who rotated on their core clinical clerkship in internal medicine during the period of July 2004 to April 2005 (n = 177) were required to complete two PDA-based mini-CEXs that were supervised by a faculty member or senior resident. Descriptive statistics and sample t test with equal variances were performed to analyze PDA-based mini-CEX completion rates, satisfaction scores by overall user and by evaluator type.During the 10-month study period, 354 PDA-based mini-CEX forms were collected (100% completion rate). Seventy-five percent (n = 267) of mini-CEXs occurred in the inpatient setting and 24% (n = 87) in the outpatient clinics. Students reported receiving feedback from their evaluator in 96% of these exercises. The most frequently evaluated competencies were humanism (90%), physical examination (90%), and overall clinical competence (90%). Third-year students were evaluated by residents in 58% (n = 205) of encounters and by faculty in 42% (n = 149). Residents rated students significantly higher than faculty (overall M = 7.6 vs. 7.1, respectively) in all clinical domains of the PDA-based form (p.05). Satisfaction with the PDA based mini-CEX was high (scale = 1-9) for residents (8.1; SD = 1.5), faculty (7.4; SD = 1.5), and students (8.0; SD = 1.7).A PDA-based mini-CEX is a feasible tool to facilitate the direct observation of students' clinical skills. The PDA-based mini-CEX was highly rated by students and evaluators as a valuable technology-based tool to document direct supervision of clinical skills.

Educators across the continuum of medical education seek to incorporate instruction that emphasizes the challenging yet critical elements of professionalism. Drawing on the elements of professionalism outlined by the American Board of Internal Medicine, this half-day workshop is explicitly designed to assist learners in applying the often abstract concepts of professionalism through structured discussions of real-life vignettes. The workshop is structured in three parts: an interactive lecture, a small-group facilitated discussion focused on professionalism vignettes, and a large-group debriefing allowing learners to identify themes and lessons learned and offering them options to safely report obvious unprofessional behavior. Small-group discussions center on the analysis of instructor- and learner-authored professionalism-related vignettes using the American Board of Internal Medicine professionalism terminology. We have received consistently high ratings for this workshop, with narrative comments focused on its overall quality and impact. More specifically, learners reported that the workshop merited an overall grade of high pass, and the facilitators concurred. Learners also rated their small-group facilitators very positively, with comments highlighting the opportunity to discuss professionalism issues with faculty in a nonpressured environment.

Teaching physical exam skills to medical students is increasingly difficult as teachers face multiple barriers including patient recruitment issues, changing physical exam findings, and subjective assessments by different raters. Additionally, teaching the physical exam often still occurs in the lecture discussion and small-group model. We created this resource to improve the knowledge and skills of medical students in the cardiopulmonary physical exam, and assess their ability to accurately identify cardiac and pulmonary auscultory sounds by using an interactive e-module in the setting of limited teacher and patient resources. The module is accessible via the internet using the course management platform ANGEL. Once students log into ANGEL, the tutorial highlights cardiopulmonary physical exam psychomotor skills, physical exam findings, and relationship to pathophysiology. The tutorial features hyperlinks to physical exam skill videos and clinical skills websites. Subsequently, case-based lessons with video interviews, audio of normal and abnormal cardiac and pulmonary auscultory sounds, pictures of abnormal physical exam findings, and X-rays for individual cases are introduced. Students are asked to identify various physical exam findings and interpret abnormal sounds, as well as make a diagnosis during the case-based portion of the tutorial. There is a pre-/postcase-based quiz administered to assess students' cardiac and pulmonary auscultory knowledge, with cardiac and pulmonary sounds embedded within the quiz. This course was piloted with third-year preclerkship students with a mean score on the knowledge quiz of 61.6% (+/- 44%) prior to intervention, rising to 93.1% (+/- 19%) after the web-based curriculum. Seventy percent of students rated the web-based module as very good or excellent. Program evaluation by students averaged > 4.0 (1 = strongly disagree, 5 = strongly agree) for satisfaction with the curriculum in helping identify abnormal cardiac and pulmonary auscultory sounds. Qualitative data indicated that medical students felt the web hyperlinks, cases, graphics, video, and audio files enhanced their learning experience. They described ease of accessibility and flexibility as key favorable components of the module.

Recent data do not exist on medical students' performance of and attitudes toward procedural and interpretive skills deemed important by medical educators.A total of 171 medical students at seven medical schools were surveyed regarding frequency of performance, self-confidence, and perceived importance of 21 procedural and interpretive skills.Of the 122 responding students (71% response rate), a majority had never performed lumbar puncture, thoracentesis, paracentesis, or blood culture, and students reported lowest self-confidence in these skills. At least one-quarter of students had never performed phlebotomy, peripheral intravenous catheter insertion, or arterial blood sampling. Students perceived all 21 skills as important to learn and perform during medical school.Through the third year of medical school, a majority of students had never performed important procedures, and a substantial minority had not performed basic procedures. Students had low self-confidence in skills they rarely performed, but perceived all skills surveyed as important.

To identify specific learning activities (and teaching methods) that students associate with high-quality teaching in the inpatient setting.For ten months in 2003-04, 170 third-year medical students recorded data on learning/feedback activities and teaching quality via personal digital assistants during the inpatient portion of a required two-month medicine clerkship at four sites affiliated with the Medical College of Wisconsin. Univariate and multivariate analyses were performed to assess the association between learning/feedback activities and students' perceptions of high-quality teaching.A total of 2,671 teaching encounters were rated by 170 students during their required inpatient medicine rotations. Bedside teaching was reported in almost two-thirds of teaching/learning encounters. Feedback on case presentation and differential diagnosis were the inpatient feedback activities most often provided by faculty. The univariate analysis revealed that students' perceptions of high-quality teaching was associated with receiving mini-lectures, developing short presentations on relevant inpatient topics, bedside teaching, case-based conferences, learning electrocardiogram and chest X-ray interpretation, teaching with other team members present (p. 001), and receiving feedback on history and physical examination, on case presentation, at the bedside, on differential diagnosis, and on daily progress notes. Results from the regression analysis revealed that giving mini-lectures on inpatient topics, teaching electrocardiogram and chest X-ray interpretation, providing feedback on case presentation, and at the bedside were predictors of overall high-quality teaching.Aspects of feedback, giving mini-lectures, and learning test-interpretation skills were the learning and feedback activities associated with students' perceptions of high-quality teaching. In an increasingly time-pressured inpatient environment, clinical educators should understand which activities students value.

PURPOSE To identify learning activities that students associate with high-quality teaching on a clinical rotation. METHOD From July to December 2001, data on patient encounters, learning activities, and teaching quality were collected via personal hand-held computers from 82 medical students during a required third-year internal medicine (IM) clerkship at the Medical College of Wisconsin, Milwaukee. Univariate (chi-square test) and multivariate analysis (stepwise multiple logistic regression) were performed to assess the association between learning activities and students' perceptions of teaching quality during this rotation. RESULTS A total of 1,839 patient encounters were recorded: 62% of these occurred in the inpatient setting and 38% in outpatient clinics. In 80% of all encounters, students reported that they gave an oral case presentation and proposed a plan; they reported receiving high-quality feedback after 64% of these presentations. Univariate analysis demonstrated that the students' perception of high-quality teaching was associated with being on an inpatient rotation, formulating an assessment, proposing a plan, presenting to the attending physician with other members of the team present, giving an oral case presentation, and receiving high-quality feedback (p

Recently published American and British guidelines have comprehensively reviewed the indications for long term anticoagulation. The best evidence currently available supports the use of long term oral anticoagulants in patients with nonvalvular atrial fibrillation (NVAF), venous thromboembolic disease, ischaemic heart disease, mural thrombi, and mechanical heart valves. Selected patients with valvular heart disease, cerebral vascular disease, and peripheral arterial disease may also benefit from the use of these drugs. When no specific contraindications are present, elderly patients with either paroxysmal or persistent NVAF should be considered candidates for treatment with anticoagulants. Pooled analyses of the results from 9 randomised trials demonstrate that warfarin significantly reduces the risk of ischaemic stroke in patients with NVAF, particularly those in a 'high risk' category defined by the presence of additional clinical or echocardiographic risk factors. Long term anticoagulation does not appear to be justified in patients with NVAF considered to be at 'low risk' for stroke. Because the prevalence of NVAF and most other cardiovascular conditions increases with advancing age, many elderly patients will be candidates for thromboprophylaxis. The potential benefit of long term anticoagulation must be carefully weighed against the risk of serious haemorrhage in such patients. Bleeding complications with anticoagulant drugs appear to occur more frequently in older patients than in younger individuals. Advanced age (>75 years), intensity of anticoagulation [International Normalised Ratio (INR) >4.0], history of cerebral vascular disease (recent or remote), and concomitant use of drugs that interfere with haemostasis [aspirin (acetylsalicylic acid) or nonsteroidal anti-inflammatory drugs] are among the most important variables in determining an individual's risk for major bleeding with anticoagulants. Older patients often display increased sensitivity to the effects of warfarin, both in the early induction phase and during the long term maintenance phase of therapy. Conditions such as congestive heart failure, malignancy, malnutrition, diarrhoea and unsuspected vitamin K deficiency, enhance the prothrombin time response. The decision to interrupt anticoagulant therapy before elective surgery in elderly patients should evaluate the thrombotic risk of such a manoeuvre versus the risk of bleeding if anticoagulants are continued. In non-surgical patients, excessively elevated INRs without associated haemorrhage can usually be managed by simply witholding one or several doses of warfarin. If more rapid reversal is needed, small doses of phytomenadione (vitamin K1) can be administered safely without overcorrection or the development of vitamin K-induced warfarin resistance.

Urine contains inhibitors of calcium oxalate (CaOx) crystal growth. One such inhibitor is nephrocalcin (NC), a glycoprotein which is made in the kidney and contains several residues of gamma-carboxyglutamic acid (Gla) per molecule. The presence of Gla may be important to its ability to inhibit crystal growth. Several studies suggest that vitamin K-dependent proteins may also play a role in renal calcium (Ca) handling, and that vitamin D deficiency may lead to excess urinary Ca loss, but the effect of the vitamin K antagonist warfarin on urinary Ca excretion and CaOx growth inhibition in humans is not known. We studied 11 men while they were taking warfarin for a mean of 252 days, and again a mean of 64 days after its discontinuation. Urinary Ca excretion did not differ between those on or off warfarin, or between those on warfarin and normal controls. The ability of the subjects' urine to inhibit CaOx crystal growth did not differ on or off warfarin, or from that of control urine, and the excretion of immunoreactive NC also did not differ between these groups. NC was found to be responsible for approximately 16% of the CaOx growth inhibition seen. These results do not suggest that vitamin K-dependent proteins play a major role in renal Ca excretion in men, or that interference with vitamin K alters NC excretion or inhibitory activity of the urine.

Objective: To identify and compare learning activities that students associate with high quality teaching across clerkships. Methods: For six months, 110 third year medical students recorded data on learning activities and teaching quality using personal digital assistants (PDAs) during five different required clinical clerkships. Univariate and multivariate analyses were performed to assess the association between learning activities and student ratings of high teaching quality. Results: 11,450 teaching interactions were recorded. Univariate analysis revealed that feedback was associated with perceptions of high quality teaching in all clerkships. Proposing a plan, for­mulating an assessment and giving an oral case presentation were associated with high quality teaching in 80% of the clerkships (p

Many patients seen in a primary care practice have multiple risk factors for cardiovascular disease. In evaluating these patients, it is important for primary care clinicians to understand the principles of multiple risk factor assessment. Although none of the large-scale randomized primary prevention trials have convincingly proven the benefits of multiple risk factor intervention, some practical guidelines reflecting the current state of information are presented.

In many patients receiving long-term oral anticoagulation therapy, hemorrhagic complications occur less often when prothrombin time is maintained within a lower range than that required by a traditional regimen. A target prothrombin time ratio of 1.3 to 1.5 has been recommended for all circumstances except (1) prevention of thromboembolism in patients with mechanical heart valves and (2) prevention of recurrent systemic embolism. Because primary care physicians often monitor the overall treatment program of patients receiving oral anticoagulants, they need to be familiar with the indications, contraindications, and practical considerations that are associated with the use of these drugs.

Ochronosis is a disease of tyrosine metabolism. Although most commonly associated with alcaptonuria and spondyloarthropathy, cardiovascular abnormalities have been associated. We describe a case which exemplifies the cardiovascular findings in this entity.